Provider Demographics
NPI:1124811450
Name:JEFFERSON STREET PRIMARY CARE CLINIC
Entity type:Organization
Organization Name:JEFFERSON STREET PRIMARY CARE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR/HR
Authorized Official - Prefix:
Authorized Official - First Name:ANTOINETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:RABENALDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-330-2576
Mailing Address - Street 1:302 HACKER ST
Mailing Address - Street 2:
Mailing Address - City:NEW IBERIA
Mailing Address - State:LA
Mailing Address - Zip Code:70560-4508
Mailing Address - Country:US
Mailing Address - Phone:337-330-2576
Mailing Address - Fax:337-417-9909
Practice Address - Street 1:618 JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70501-7206
Practice Address - Country:US
Practice Address - Phone:337-345-1965
Practice Address - Fax:337-345-4227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-28
Last Update Date:2025-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care